Cost-Effectiveness of Intraoperative Facial Nerve Monitoring in Otologic Surgery

Objective: Evaluate the cost-effectiveness of intraoperative facial nerve monitoring (FNM) during otologic/neurotologic surgery. Study design: Decision-tree cost-effectiveness analysis with probabilistic sensitivity analysis using 1000-iteration Monte Carlo simulation. Setting: Tertiary academic center. Patients: Hypothetical adult cohort undergoing otologic surgery. Interventions: FNM for all otologic surgeries, FNM for revision surgeries only, and no FNM. Main outcome measures: Expected quality-adjusted life years (QALYs), expected cost per patient, incremental cost-effectiveness ratio (ICER; difference in cost/difference in QALY), and probability of cost-effectiveness at willingness-to-pay thresholds. Results: FNM for all otologic surgeries (both primary and revision) was associated with an increase in QALYs of 0.18 compared with no monitoring. Average cost increased by $169.99 per patient for equipment purchased from vendor 1 (ICER=$968.21/QALY), by $58.99 with vendor 2 (ICER=$336.00/QALY), and by $6.99 with vendor 3 (ICER=$39.83/QALY). Probabilistic sensitivity analysis demonstrated that monitoring all otologic surgeries was the most cost-effective strategy in most simulations (93% for vendor 1, 96% for vendor 2, and 95% for vendor 3) at a $50,000/QALY willingness-to-pay threshold. Sensitivity analysis suggested FNM to be cost-effective over a wide range of costs and probabilities. Conclusions: FNM for otologic surgery is cost-effective across vendors. Although use of higher-cost electrodes leads to increases in per-patient cost, the incremental cost per QALY gained remains minimal and well below accepted thresholds. These findings suggest routine FNM use in all cases is cost-effective, particularly in institutions with surgical volume to exceed break-even thresholds.